1925 - browne - cord abnormalities and iufd

On the Abnormalities of the Umbilical Cord which may cause Antenatal Death.

FRANCIS J. RROWNE, M.D. (Aberd.), F.R.C.S. (Edin.), Assistant Physician, Edinburgh Royal Maternity Hospital.

TRUE KNOTS ON THE CORD. The occurrence of true knots on the umbilical cord must be

looked upon as somewhat rare. According to Von Winckel they are present in 0.4 per cent. to 0.5 per cent. of all births, while Chantreuil states that out of 6,075 deliveries observed in the HBpital des Cliniqules, Paris, seven knots were found, six simple and one double, i.e., about one in 1,000 deliveries. v. Hecker records 31,590 births in which true knots occurred 1 1 5 times, or once in 274 cases, and in no case was the child injured. In the great majority of cases in which true knots are present they are comparatively slack and have no effect upon the development o r life of the fe tus . Indeed, the opinion has been frequently expressed that they can never be drawn sufficiently tight before labour to obstruct the circulation in the cord and thus be a cause of f e t a l death. Baudelocque was one of the chief exponents of this view and stated that in some cases he had found even two knots present and the f e t u s alive and as large as usual. In one interesting case which he figures, the cord was three times knotted, one knot being interlaced in the other, and still the child was born alive and healthy. T h e knot was situated about a foot from the umbilicus and was drawn “ as tight as any knot could be in such a case.” Baudelocque the younger reported three cases of cord knots in two of which the knots were double and were so tight that they left, at the part of the cord where they were situated, a deep furrow-like depression, and yet the infants were born alive and well. Gardien says “ when the umbilical cord is very long, it may become entwined around the child’s neck and may even form knots ; they can never tighten themselves during the pregnancy sufficiently to cause the death of the f e t u s .or interfere with its growth.”

Chantreuil, on the other hand, thinlts that thry may be a cause of intrauterine death, and that even though born alive the child may be thin and ill-nourished. Levret says : “One sometimes

C

J Obs Gyn Brit Emp 1925 V-32

history-of-obgyn.com

I 8 Journal of Obstetrics and Gynaxology

find5 the umbilical cord knotted in a true knot, it is sometimes twisted so as to be doubled, or it may occasionally be even separated from the placenta; \ \hen one of these t h e e circum- stances occurs the foetus usually perishes before term or it is at least much emaciated.”

Jacquemier says : “ The knots that the ftetus forms in passing through a loop of cord appear rarely to block the circulation. It is, however possible that the fetal movements can tighten a knot sufficiently to block tlie circulation, but it is diflicuit to bring fom a‘-d convincing examples of death caused in this way.”

Naegele and Grenser state that while knots arising during pregnancy are usually harmless, some facts scem to demonstrate that they may exceptionallv block the circulation of the cord and thus cause atrophy and death of the f e t u s ; “ One has often met with these h o t s on an umbilical cord of fe tuses born macerated, but it will always be uncertain if in these cases the knots were not tightened only after death of the fetus .”

Smellie, describing a case of f e t a l death n hich lie attributes to a knot on tlie cord, says : “ If the navel string be long and the quantity of surrounding \raters great, the fmtus, while young, may, in s\v‘imniing, form a noose of the funis through which, should the whole f e t u s pass, a knot \ r i l l he formed on the navel string which, i f tightly drawn TI i l l absolutely obstruct the circulation.”

Tarnier made a knot on a cord and pulled it as t ight a s possible, then injected fluid, and alnays found that the fluid could pass. FIe found that uhen the vessels proximal to thc Itnot swelled up with fluid tlie knot partlv untied itself, and he thinks the same nould happen by tlie foetal heart pumping the blood through the umbilical vessrls. I t n a s only on putting three knots on the cord a s closely together as possible that any resistance was experienced. This, it may be said in passing, appears to be an altogether ilnjustitiable conclusion, for no statement is given concerning the pressure at which the injection n a s made or evidence adduced that i t \ \as not many times greater than that propelling the blood through the vessels- of the cord. Ixfour and Oui more rccently showed that the slight weight of 2 5 to 90 grins. attached to the co1.d sufficed to tighten a slack knot siifficiently to cut off an artificial circulation in the cord. These observations are in accordance with my ov n findings, which are briefly as follows :-

An umbilical cord n as talien an hour after delivery and separated from the plaoenta. A glass canula was fitted into the vein, while to the other end of the canula \+as fixed a long rubber tubeconnected \I ith :t mercurv manometer.

’I‘hrough the open end o f the tube nater \YRS injected b j r means of n large Record sj-ringe. During the c u p ~ i m e n t s the surface of


Abnormalities of the Umbilical Cord 19

the cord was kept well lubricated with vaseline in order that its slippery surface might a s nearly a s possible resemble that present during intra-uterine life.

It \vas found that when there was no knot on the cord the fluid passed through it at a pressure of 10 mm. of mercury.

I V h m one slack Itnot \\as put on the cord ar,d no weight attached, and the knot not in any \vav tiglitened, the fluid passed through a t ;I pressure of 20 mni. Even the slackest knot, therefore, caused some obstruction, and this was made evident by the visible swelling- and engorgement o f the cord on the proximal side of the Itnot. Kext the strands of cord involved in the knot became engorged and finally the fluid passed, the knot hecoming p u t l ? opened out at the same time.

\IThen two true knots were formed, one superimposed on the other, the fluid passed a t a pressure of 60 mm.

single true knot was placed in the cord, and a weight of 2 0 grms. nas tied to its distal end. No attempt nas made to tighten the h o t except bv the weight attached to the end. T h e fluid passed at a pressure of 40 mni.

Wi th a weight of 5 0 grms. a pressure of 70 rnm. was required. Il’ith a weight of 100 grnis. a pressure of I O C F - I I O ~ ~ . was

IVith a weight of 140grms., 140-150 mm. n a s necessary. IVith a weight of 160 grms. fluid failed to pass at a pressure

of 165-170 mm. The arterial pressure in the umbilical cord varies from ?9 3 to

83.7 mm., while the venous pressure is about 16 mm. (Feldrnan). These experiments show that e~7en a slack knot mav he suf-

ficient to interfere ivith, if not completely to obstruct, the cord circulation, but that any pull upon the knot such as might be exerted i f the cord were uound around the child’s neck o r bod!, so as to cause a relative shortening of it, would easily cause sufficient tightening to impede the circulation completely.

required.

.\lode o j Formation. T h e chief causes which predispose to the formation of knots appear to he : ( I ) undue length of the cord; (2) hydramnios; and (3 ) exaggerated foetal movements ; while by some the occurrence has been attributed t o violent movement on the part of the motber (Gutcrman) follon-ed by tnniultous foctal mowments uhich afterwards i m m ed in t e 1 y ;I t j n or ma1 length of the cord appears to predisposc, instances are not wanting in nliich a true Imot was found upon an exceedingly short cord. Thus in the case of (I‘ollyns the cord \!-as only s is inches long and had 1\10 knots, the f e t u s being almost in contact

and pv r nian en t 1 y ceased. 1\7 1 i I e


2 0

with the placenta. In the case of Woets the knotted cord was only 14 inches long. Abundance of liquor amnii will obviously facilitate fetal movements and thus favour knot formation. Schneider held that the h o t s cannot be formed by f e t a l movements but are pre-existing and of developmental origin. Th i s opinion is not generally held, the usual view being that the f e t u s swimming in the liquor amnii passes accidentally through a noose of the cord. If it passes only partially through the noose a coil is formed around the neck or body. If, before passing through the loop, it first passes under the cord and then over the adjacent limb of the noose, or if it first twists itself around the placental end of the cord, a complicated Itnot is formed. If the loop is double when it passes through, i .~.. contains txvo strands in its whole circumference, a figure of eight Itnot results. During labour a true knot may result from the f e t u s passing through a loop spread out in the lower uterine segment. I t is obvious that the formation of a Itnot leads to some shortening of the cord. This of itself may, if the cord is unduly short to start with, lead to the tightening of the knot bv the mere weight or movements of the f e tus , but tightening is more likely to occur i f in addition the cord is wound round the neck, body or limbs. T h e mere movements of the f e t u s may then suflice to tighten the Itnot. In this connection it is of interest to note that in a number of the cases in which death of the f e t u s was attributed to a Itnot on the cord it is recorded that the latter was wound once or twice around the body or neck. I t is probable that a slight interference with the circulation produced by a comparatively slack Itnot may lead to such violent f e t a l movements that the knot may be tightened sufficiently to cause complete obstruction.

Van Swieten, quoted bv Naegele and Grenser, reports the case of a woman who, in two successive pregnancies, gave birth to a dead f e tus , and each time there as a very tightly drawn knot on the cord.

According- to Chantreuil, the formation of lrnots is most likely to occur between the ninth and twelfth week when the f e t u s is small and the movements free owing to the relativelv large amount of liquor amnii.

According to IIyrtl, the time of formation of the knot may be in some degree indicated by its situation. Thus, if close to the navel, it was probably formed at an early period of pregnancy. I t must be noted, however, as pointed out by Chantreuil, that considering the slippery surface of the cord and the slackness of the knot immediatelv after its formation. it is not inconceivable that it might slide in one or other direction. This is a fact that mav be easily verified by anjone. During the injection experi-

Journal of Obstetrics and Gynaecology


Abnormalities of the Umbilical Cord 2 1

ments detailed above, I found that the engorgement and swelling of the cord from accumulation of fluid behind the knot was frequently sufficient in itself to shift the knot downwards from two to six inches.

Anatomical Changes in the Cord. Mere it is necessary to make a distinction between old and recent knots. In tlie latter, which are usually formed during labour, there are no anatomical changes, excepting possibly some e d e m a on the f e t a l side of the cord. In old knots, on the other hand, in which the knot has been drawn sufficiently tight to obstruct the circulation, there are usually well marked changes whicli may be described a s follows :-

( I ) There is marked and permanent grooving of the cord at the site of the knot, by the loops forming it.

(2) A t the compressed parts of the knot there is niore or less complete disappearance of the jelly of Wharton, and all the portions of the cord entering into the knot may be flat and band-like.

( 3 ) When the knot is undone there is persistent curling of the cord a t the part where the knot formerly existed.

(4) T h e vessels in the knotted part are compressed and their calibre diminished while, as in the case of Holzapfel (vide inf ra), the vessels in the proximal part of the cord may have their walls thickened by increase of the fibrous and muscular tissue due, possibly, to hypertrophy of threir coats. In some of the recorded cases, after undoing the knot, tlie vessels were found to be impervious to injection.

(5) Tha t portion of cord between the fmtus and knot (the proximal part) may be edematous while the distant part may be thin and pale, as in Holzapfel’s case, and the cases of Canivet and Hannay. In Veit’s case, on the other hand, and in that of Ronnaire and Schwab, it was the placental end of the cord that appears to have been swollen, while in the last mentioned case the placenta also was edematous.

(6) In six out of 23 cases which I have collected from the literature it is recorded that the cord was looped round the neck, and in one of these it surrounded it three times; in another it so tightly compressed the soft tissues of the neck against the vertebral column that the f e t u s was almost decapitated.

S i g n s and .Sym$ioms. In most cases the only symptom present is cessation, usually sudden, of the foetal movements. Sometimes this has been preceded by When this occurs it is probably to be looked upon as due to gradual asphyxiation of the f e t u s from tightening of a knot previously formed and not a s the cause of knot formation. It is recorded i n nine out of 24 cases tabulated below. In three cases it is specifically stated that the movements ceased gradually. A s the cessation of

undue activity of the fe tus .


2 2 Journal of Obstetrics and Gynzcology

f e t a l movement coincides 1% it11 f e t a l death, t he uterus cvase5 to develop and the abdomen to increase in size. In short all the signs oi" f e t a l death \\ill gradually become appaic'nt. ;\ij o\\ n experience of true ltnots in the case of dead fmtuses is limited to two cases. 1 have, besides, tuice seen true ltnots on the cords of infants born alive and healthy. In neither of these cases, however, u a s the knot a t all tight.

Case I . Three-para, aged 3 1 , previous three children alive and healthy, the youngest aged two. T h e mother had always been healthy and tlie present pregnancy was normal until three neeks before de!ivery, lvhen f e t a l movements ceased to be felt. Apparently, no other symptoms had been noticed. T h e patient was confinmed a t her own home, n here the fwtus nas born before arrival of the nurses. I t uas a premature macerated f e tus , 1215 grms. in weight and 42 cm. long. and judging from the degree ot maceration, had apparentlv been dead about the period during i\ hich no movements had been noticed, viz., three neelis. T h e

l i v t a r \\ ,l,glied 33 grins., spleen 1.5 grms., placenta 152 grms., small and pale and shon ing no hzmorrhage nor pathological infarction; cord Go cm. long and a t the middle showed a simple true knot which \\as w r y tiglitlv dralvn but easily undone. There was no histoiy leading one to suspect the presence of syphilis. Spirochztes were absent from the foetal organs, and in the absence of any other demonstrable cause of death it seems probable, although unproven, that the lcnot nas the cause.

Case 2 . One-para aged 18, healthv and mairied over txvo \eirs ; tirst child alive and well, aged 14 months. T h e father, also, so far as could be ascertained was healthy. Labour was precipi- tate a t fu l l time, a male child being born alive and well, followed by an acardiac fetus and the placenta, before arrival of the midwifle. T h e living child had a slight deformity of one thumb which was flail-lilte on account of congenital absence of the metacarpal bone. T h e acardiac f e t u s was sent to me with the placenta and the above history bv Dr. Allan Rutherford, Barrow-in-Furness. T h e acardiac f e t u s was badly macerated (papyraceous), and was repre- sented by two loxver linibs of fairly normal appearance, a pelvis, and a badly formed abdomen, to the upper margin of which there was attached a rudimentary upper limb. T h e umbilicus was repre- sented by a slightly elevated papilla, partly surrounded by a furrow a t the lo\ver margin of attachment of the upper extremity ; (a full description of tlie specinicn will be found in the Trans. Edin. Obst.

T h e umbilical cord of the acardiac fetus joined the cord of the other f e t u s one inch from its root. There seemed to bz an anastu- mosis between the vein in the cord of tlie normal fwtus and that o( the cord of the aiardiac f e tus , in the last inch of coninion cord.

Soc. 10th l l ay , 1923.)


Abnormalities of the Umbilical Cord 2 3

In the cord of the acardiac f e t u s there seemed to be no abnormality on microscopic examination, there being present t v o arteries and one vein. In the root of the cord, l i o~eve r , and close to the abdomen, there was a sac which contained a few coils of intestine. About one inch distal to this there \\as a true knot on the cord, very tightly drawn, which may have been the cause of fmtal death. In such a monster as this, however, there is sufficient cause of death present without invoking any other ; the most interesting feature in the case is that it is impossible to conceive of such a headless and almost limbless monstrosity indulging in active movements, so that the latter seem to be somewhat discounted :IS an important cause of the formation of cord knots. The circulation in the acardiac foetus was probably carried on by means of the heart of the normal f e t u s which drove a certain quantity of pure venous blood through the cord of the former to the rudimentary limbs, whence by vis u tergo i t was returned through the two small umbilical arteries into the common placental circulation. The tn o placental circulations must, therefore, necessarily have communi- cated, possibly in the common part of the cord.

Knotted Cords in Monamniotic Twins. Several cases have been recorded in which i n monamniotic twins the cords were linotted together or otherwise entangled, usually leading to death of one or both. In Pallin’s case, however, the children, which were born at the eighth month with their cords knotted togethler, livcd two and three days respectively. In Lindsay’s case the cords were in actual contact a t their origin and were twisted around one another and tied in a knot ; both twins were dead born and macerated. Jeannin reported a case in which the cords were inserted velamentously into the single placenta 5 cni. apart, and were tied together in a figure 8 double knot suficientlv tight to flatten their substance. In Newman’s case the two cords sprang from the centre of the single placenta about one inch apart. Each cord was about 24 inches long, and “ about midway between the umbilicus and the placental attachment of the funis the cord of the first child was tied in a single knot, and passing through the noose so formed was the cord of the second child, which, on account oi the tightening of the knot, was completely strangulated.”

The first child was born alive and well, but the second dead and livid (not macerated), death having apparently occurred during labour. In Weston’s case the cord of one twin had passed through a knot on the cord of the other ; the latter was then tied so tightly that the circulation in both cords was interrupted and both children killed three weeks before birth.

The cases 26 in number, of f e t a l death due to true knots on the cord which I have been able to collPct from the literature are given in the following table :-


Len

gth

No.

S

itua

tion

V

arie

ty

Alle

ged.

of

of

of of

Pres

en-

Obs

erve

r. So

urce

. A

ge.

Pari

ty.

caus

e.

Sym

ptom

s.

cord

. kn

ots.

kn

ot.

knot

. ta

tion

. R

emar

ks.

Fra

nk.

Ant

er.

Jour

n. O

bst.

31

I N

one.

C

essa

tion

of

90 cm

. I

30 c

m. f

rom

Si

mpl

e.

-

19078

55,

790.

So

me

exce

ss

feta

l m

ove-

pl

acen

ta.

of liq

uor

men

ts o

nly.

am

nii.

Wal

linge

r.

Bri

t. M

ed.

Jou

rn.,

49

13

Non

e.

Chi

ld

-

I gi

ns. f

rom

-

Bre

ech.

K

not

tied

so t

ight

as

1908,

ii, 147.

seem

ed t

o um

bilic

us.

to s

top

circ

ulat

ion.

tu

rn o

ver,

then

mov

e-

inen

ts c

ease

d.

--

_-

Sank

ey.

Lund

. O

bst.

Tra

ns.,

43

6 N

one.

M

ovem

ents

-

I M

iddl

e.

Sim

ple

-

Kno

t no

t ve

ry t

ight

- ii

i, 413.

grew

dai

ly

and

poss

ibly

no

t ca

use

of fa

inte

r fr

om

sing

le.

deat

h.

6th

mon

th.

-

_- Pa

ssot

. R

ev.

Med

. et

ch

ir:

-

-

-

Mov

emen

ts

IIO

cm.

2 I

at i

nfer

ior

Sim

ple

Ver

tex.

B

oth

knot

s ve

ry t

ight

; de

Par

is, 1869, T v,

grad

uall

y I

at t

he

umbi

lical

re

in

coul

d 37

0.

less

ened

. su

peri

or t

hird

. no

t be

in

ject

ed

past

th

e kn

ot. -

-

Woe

ts.

An

n. d

e la

SO

C. M

ed.

-

5 C

hir.

de

B

ruge

s,

T ii

i, 1842.

-

14 in

s. -

Mid

dle

-

-

Tig

ht.

Gri

eve.

Lo

ndon

an

d E

din.

- -

3 w

ks.

befo

re

-

-

- M

iddl

e.

-

Ver

tex.

T

ight

eno

ugh

to i

nter

- M

onth

ly

Jl.,

1842,

term

sei

zed

rupt

the

cir

cula

tion.

P.

23.

w

ith l

abou

r pa

ins

and

slig

ht

haem

or-

rhag

e.

Pass

ed o

ff w

ith o

pium

.


Len

gth

No.

Si

tuat

ioii

V

arie

ty

Alle

ged.

of

of

of

of

Pres

en-

Obs

erve

r. So

urce

. A

ge.

Pari

ty.

caus

e.

Sym

ptom

s.

cord

. kn

ots.

kn

ot.

knot

. ta

tion

. R

emar

ks.

Piog

ey.

Bul

l.

de

la

Soci

6tb

-

Ana

t. d

e Paris, 18

52,

xxvi

i, 17

6.

-

-

I C

entr

e.

-

-

I

Han

nay.

L

ond.

Med

. G

azet

te,

26

3 Su

dden

T

umul

tuou

s -

I N

ear

cent

re.

Sing

le.

-

1841, p

. 122.

mov

emen

t m

otio

ns o

f of

m

othe

r.

fetu

s fo

llow

ed

nios

. N

o hy

dram

- by

ces

sati

on.

On

unty

ing

it t

wo

dis-

ti

nct

depr

essi

ons

left

.

Cor

d on

ce r

ound

nec

k.

Kno

t ti

ghtl

y dr

awn.

P

art

of co

rd

knot

ted

only

hal

f th

ickn

ess

of

the

rest

; ar

teri

es f

rom

kn

ot t

o fo

etus

inje

cted

. P

art

of

cord

be

yond

ex

sang

uine

, al

so p

la-

cent

a.

-

Sine

llie.

“ T

heor

y an

d Pr

ac-

-

-

Col

ic.

Non

e ex

cept

-

I 10 h

and-

-

-

Cor

d I‘

sw

elle

d an

d tic

e of

M

idw

ifer

y,”

colic

. br

eadt

hs

livi

d” a

nd k

not

tigh

t.

vol.

ii.

alon

g.

G6r

y.

1’U

nion

?$E

d.,

Seri

es

32

2 -

Tum

ultu

ous

-

I Ju

ncti

on

of -

-

Alb

umin

uria

; p

lace

nta

3, 1

S76,

xxi

i, 88

6.

mov

emen

ts o

f um

bili

cal

show

ed

apop

lect

ic

fetu

s fo

llow

ed

two-

thir

ds

h:em

ori-

hage

s.

by g

radu

al

with

pla

cent

al

cess

atio

n.

one-

thir

d.

Xug

ouar

d.

Dit

to.

-

-

-

Ces

satio

n of

-

I -

-

Bre

ech.

T

ight

kno

t w

here

loop

s fe

tal

mov

e-

of

knot

cr

osse

d th

e m

ents

onl

y.

cord

, re

duce

d to

one

- fif

th i

ts

norm

al

bulk

. T

he c

ompr

esse

d pa

rts

appe

ared

fib

rous

.


Len

gth

No.

Si

tuat

ion

Var

iety

A

llege

d.

of

of of

of Pr

esen

- O

bser

ver.

So

urce

. A

ge.

Par

ity.

ca

use.

Sy

mpt

oms.

co

rd.

knot

s.

knot

. kn

ot.

tati

on.

Rem

arks

.

Piog

ey.

Bul

l. d

e la

Sac

. Ana

t. -

I -

On

com

ing

-

‘I

Tow

ards

-

-

Cor

d ex

sang

uine

hFl

ow

mid

dle.

bu

t ye

ry

swol

len

de f

’uri

s, 1

8 j2, x

xvii,

ou

t of

her

176.

ba

th h

ad f

elt

abov

e. Two

deep

ini

- ch

ild m

ove

pres

sion

s pr

esen

t at

ve

ry a

ctiv

ely.

le

vel

of kn

ot.

Sinc

e th

en

had

ceas

ed

to m

ove.

__

.~

~

~-

~~

__

___--

~~

__

B

illi.

An

n.

Uni

vers

ale

di

24

2 -

-

g~

cm

. I

14 in

s. f

rom

-

Bre

ech.

C

ord

form

ed t

wo

loop

s ro

und

t riii

i k ,

the

2nd

of w

hich

stlo

wed

a tr

ue

knot

. In

ject

ions

int

o th

e ve

in c

oiild

not

pas

s kn

ot.

Med

icin

a, 1

857,

clx

i,

plac

enta

.

_-

- ~

~ -

Iiill

i. D

itto.

3s

I

Non

e Fo

etal

mov

e-

26cm

. I

Mid

dle.

-

Ver

tex.

C

ord

loop

ed

twic

e kn

own.

m

ents

bec

ame

arou

nd n

eck

of

fetu

s ;

wry

vio

lent

th

e sc

cont

l sh

owed

a

at 6

th m

onth

, ti

ght

knot

. co

ntin

ued

so

two

mon

ths,

th

en c

ease

d co

mpl

etel

y.

Bel

luzz

i. B

ullc

tiito

dc

lla

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-

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tip.

-

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lent

23 c

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I 9

ins.

fro

m

Sim

ple.

-

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d ar

ound

nec

k an

d kn

ot t

ight

eno

ugh

to

enca

m

edic

ha

di

mov

emen

ts

nave

l. B

olog

na,

Seri

e iv

, w

hich

cea

sed

com

plet

ely

inte

rrup

t ci

rcul

atio

n.

Vol

. xi

ii,

1660

, p.

at

end

of

288.

8t

h m

onth

.


Len

gth

NO

. Si

tuat

ion

Var

iety

A

llege

d.

or of

of

of

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en-

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erve

r.

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ce.

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. Pa

rity

. ca

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mpt

oms.

co

rd.

knot

s.

knot

. kn

ot.

tati

on.

Rem

arks

.

Ver

tex.

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irst

of

twin

s; s

econ

d 1875, i

v, 2

6s.

nave

l. d

ive

and

wel

l. C

ord

thie

e ti

mes

ro

und

neck

of

ftet

us.

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tw

een

knot

and

um

bili

- cu

s co

rd

cong

este

d.

F’~I

IIL

III~

~I~

groo

ves

in

knot

and

inj

ecti

on o

f ve

in f

aile

1 t

o pa

ss i

t.

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ivet

. A

rtti

. dc

G

?itC

col.,

38

5

-

-

95 c

m.

I 10 cm

. fr

om

-

~ ._

__

_

__

_

-__

_

-~

Wes

ton,

A

mcr

. Jo

urit

. O

bst.

, -

I St

oope

d to

lif

t so

me

-

1

-

-

-

Sing

le,

tigh

tly

draw

n E.

H.

1893

, xxL

iii,

14

4.

heav

y ob

ject

and

on

knot

whi

ch c

ompl

etel

y ri

sing

fe

lt

unus

ual

inte

rrup

ted

the

um-

com

mot

ion

in a

bdo-

bi

lical

cir

cula

tion

. ni

en

but

110

feta

l m

ovem

ent

afte

r.

__

_-

~ -

-~

Bon

nair

e I’

Obs

tetr

ique

, 19

05,

19

I -

-

77 c

m.

I -

Old

. -

Hyd

roce

phal

ic f

etus

. an

d x,

25

4.

Schw

ab.

Uct

\~ec

n kno

t an

d fe

tus

cord

was

pal

e re

d, b

etw

een

knot

and

pla

cent

a pu

rple

an

d th

ick.

K

not

was

im

poss

ible

to

un

tie :

jell

y of

M

’har

ton

disa

ppea

red.

V

esse

ls o

f co

rd c

ompl

etel

y im

perv

ious

to

inje

ctio

n ;

plac

enta

m

icro

scop

ical

ly

is

edem

atou

s.

No

evid

ence

of

syph

ilis

in

plac

enta

or

el

sew

here

.

Vei

t. Ze

itsch

r.

fiir

G

eb. -

--

und

Gyn

akol

., 1

893,

xx

v, 3

67.

-

I -

Mov

emen

ts

-

ceas

ed s

ud-

denl

y 14

days

bef

ore

deliv

ery.

-

Sing

le

coil

of co

rd

roun

d ne

ck p

lus

true

kn

ot

whi

ch

rest

s ag

ains

t an

teri

or

sur-

fa

ce o

f ne

ck.

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t is

tig

htly

dra

wn

and

beyo

nd i

t th

e co

rd i

s co

nges

ted.

Po

st-m

orte

m

exam

inat

ion

faile

d to

sho

w a

ny o

ther

cau

se o

f de

ath.


Len

gth

No.

S

itua

tion

V

arie

ty

Alle

ged.

of

of

of of

Pres

en-

Obs

erve

r.

Sour

ce.

Age

. Pa

rity

. ca

use.

Sy

mpt

oms.

co

rd.

knot

s.

knot

. kn

ot.

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on.

Rem

arks

.

Bar

tsch

er.

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atss

chr.

f.

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eb. -

5 Po

ssib

ly

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al m

ove-

25 in

s.

I I

-

-

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d al

way

s ro

und

1861

, p.

364

. hy

dram

nios

. m

ent

at e

nd

neck

in

pr

evio

us

Cor

d ha

d of

7t

h m

onth

bi

rths

. C

ord

twic

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ry l

ittl

e go

t ve

ry

roun

d ne

ck.

jell

y.

activ

e, t

hen

ceas

ed.

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kii

ot w

as d

iffi

cult

to u

ndo

and

the

coils

aro

und

the

neck

wer

e dr

awn

so t

ight

ly t

hat

the

child

was

alm

ost

deca

pita

ted ; t

he s

oft

part

s of

the

neck

w

ere

pres

sed

tight

ly a

gain

st th

e ve

rteb

ral

colu

mn.

-_

H

olza

pfel

. Z

eits

chr.

fu

r G

eb.

24

I -

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satio

n 11

8cm

. I

Mid

dle.

-

-

Cor

d ha

d on

ly

one

un

d

Gyn

akol

., B

d.

of f

etal

ar

tery

an

d on

e ve

in.

lxxi

v, H

ft.

I.

mov

emen

ts

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al

half

of co

rd

2 da

ys b

efor

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emat

ous;

par

t be

- on

set

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bour

. tw

een

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a-

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in

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. In

foe

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ve

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d w

alls

th

icke

ned

part

ly

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cede

ma

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ly b

y in

crea

se

of

mus

cula

r an

d fi

brou

s ti

ssue

.

Cra

wfo

rd.

Surf

., G

yn.

and

44

6 U

ndue

C

essa

tion

Nor

mal

. 4

__

-

-

Cor

d tw

ice

roun

d ne

ck.

Obs

tet.,

xxx

iv,

546.

ac

tivi

ty o

f of

fwta

l C

hild

no

rmal

ly

de-

feta

l in

ovem

ents

. ve

lope

d bu

t m

acer

- m

ovem

ents

. at

ed.


Len

gth

No.

Si

tuat

ion

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A

llege

d.

of of

of of

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knot

. ta

tictn

. R

emar

ks.

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erve

r.

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ce.

Age

. Pa

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. ca

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mpt

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co

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knot

. -

-~

___

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ot p

ubli

shed

. 31

4

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e C

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60 c

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ple.

-

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etu

s m

acer

ated

. F.

J.

know

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ents

3

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y.

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din.

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z

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Si

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c fet

us.

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- F

. J.

M

ay I

oth,

197

.3. fe

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__

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etu

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mon

s.

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d 24

ti

mes

le

ngth

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uthb

ert.

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t. Jo

urii.

, 1874-5,

30

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ral

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g A

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17

ins.

I

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er c

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mpl

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-

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ious

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ck.

fetu

s.

17in

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I 3i

ns.

from

-

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s. f

rom

um

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cus

1872

, xii

i.

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s an

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nd.

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tet.

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ns.,

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d. -

3 -

Non

e.


30 journal of Obstetrics and Gynzcology

ANTENATAL DE.\TH DUE TO THE Coiiu ENCIRCLING . ~ N D

(‘OMPRESSING THE CHILD’S NECK.

It is very rarely indeed that this condition leads to f e t a l death except during delivery, but a few cases have been recorded.

I n Bartscher’s case the woman was pregnant for the fifth time. T h e previous four children were healthv, but each had been born u i th the cord around the neck. At the end of the seventh month a very severe pain was complained of in the right lumbar region, and at the same time the f e t a l movements became very active. This pain lasted but a few days, and u i th its cessation f e t a l movements also ceased. Next day the mother complained only of a heavy weight in the abdomen, then, ten or twelve days after, she complained of repeated shivering fits and sickness. Delivery occurred a t the end of the ninth month and nas slow and tedious. Theliquor amni inas copious and foul smelling and the fmtus macerated. T h e cord, 25 inches long, had very little JVIialton’s jell\. and was in some parts ligamentous. I t had a true linot and encircled the neck of the child twice, and s o tightly that the soft purts were comfiressed aguinsi the certebral column.

Hillairel’s cuse ; In this case the historv n a s as follows :

C, miscarriage a t six months. CZ full time hcalthy girl ; cord tvice round neck; born

C 3 abortion three months. C, female at term ; cord once round neck ; alive and well.

Cy.5 boy, full t ime; cord once round necli. C , 4 mos. male f e t u s , 9 cm. long.

asphyxiated, but restored.

T h e cord \\as not insrrted in the middle line of the fetus bLlt someuhat tonards the right.

From this point it passed to the right, o u t \ ~ n ! d s a n d kacli\iards, round the child’s side, malting a deep f u r m u hctueern the lou7er ribs rind the iliac crest. Thence i t crossed the back diagonally, making there also a deep furrow until i t reached the highest point of the left scapula, then across the left slioulder and over the anterior surfacc of the neck, ovcr the right lateral surface, across the back of the neck, and so returned to the left shorildler after having made a complete circle. I t continued to roil itself around the ncck, and i n this wa!~ made three complete turns, after \\hich i t had a l l bern used up. T h e constriction had almost com!)letel!- amputated the head, the constricted part k i n g cone-shaped, the base of the cord being ahove and the apex helon. At the apex the



head was only united to the trunk by a pedicle not more than I;

mm. across.

Trdlat’s case : The f e t u s had the appearance of an abortion of 3-4 months, length p r o cm. T h e cord, verv slender at its origin from the umbilicus, formed a loop which Itclpt the right leg tight against the abdomen and lower part of the thorax. T h e cord passed thence around the neck two or three times making a deep trench, and from there it wound itself around the upper part of the trunk three or four times, and fixed the right upper limb, over the wrist of n hich it passed, the forearm being flexed on the arm. On the left side the cord passed under the axilla. From the illustration accompanying the text the cord appeared tight enough to have arrested the circulation in the neck, for a deep groove is present in the neck and upper part of chest. The f e t u s was evidently macerated.

A similar condition was present in Hlume’s case, reported by Schroeder, the soft parts of the neck being compressed even to the vertebral column by several coils of cord encircling it.

In a case described br Cleemnn the cord encircled the neck and left arm three times, the- latter being perpendicularly elevated and closely bound by the cord to the side of the head. T h e f e t u s was dead, about the fourth month of development, and the author considered death to be due to the interference with the cerebral circulation caused by the constriction of the neck.

If the cord encircles a limb the circulation in the former may be sufficiently interfered with by the pressure on the limb to cause f e t a l death. Such cases, however, seem to end more frequently in partial o r complete amputation of the limb, with continued life of the f e tus .

In a case described by Sinltler the pressure of the cord had caused a deep sulcus on the limb. and the consequent compression of the cord had led to the death of the foetus. This condition would arise when the cord had become wound around the limb at a very early stage of development, and the loop failed to become correspondingly large as the limb increased in girth.

. i,4 T ( > l < S l o N OF THE CORD.

Idil;e knots on the cord, this is one of the rare causes of f e t a l death. According to Dohin, the condition u a s first described by Kuysch in 1691. I’rohablv the best paper on the subject is CI antreuil’s mcinograph, a n i Dohrn, i n 1861, collected 85 cases from the literature. T h e torsion may affe:t the entire cord and thc number of twists may be very numerous, Dohrn finding 8j on a


32 Journal of Obstetrics and Gynaecology

cord nine inches long, belonging to a f e t u s at the end of the fourth month of pregnancy, and Mecltel 95 on a cord four inches long. In a 1 2 inch cord in my own collection there are 49 twists. Frequently, however, the inch ;r two of cord close to the umbilicus is alone affected owing, it is said, to the scarcity of t h t jelly of Wharton at that situation; less often a similar area close to the placenta is involved, or various parts of the cord may be affected even in the one specirnen. Again, the inch or so of cord close to the umbilicus may be extremely constricted. Very slight or no torsion of this part may be present, but there may be excessive twisting of the thicker part of the cord as in one of Dohrn's cases. Excessive constriction of the cord a t i ts f e t a l end may be the only abnormality present, and twisting be entirely absent.

The &Vormul Twisfing of the C o r d : A certain amount of twisting of the cord is, of course, physiological in the human subject, the arteries being tnisted around the vein usually from riglit to left, and its function is probably protective, the firm and incompressible arteries preventing injurious pressure upon the thin walled, deeper lying vein.

Seugebauer found that out of 160 cords, I 14 were twisted to the left a n d 39 to the right, Tvfiile seven showed no twisting whatever. (By ' ( to the left " is meant that starting from the anterior surface of the cord a t the umbilicus, the cord is directed towards the left, thence it passes behind, and from there to the right, and so on until the placenta is reached.) Tarnier, out of 150 cords, found the spiral directed 105 times from right to left and 45 times from left to right. Various explanations of this physiological torsion have been given, probably the most satisfactorv being that of John Simpson, who put it down to the fact that the right iliac arterv is more the direct continuation of the aorta than the left iliac. The abrta lies, in the dorsal region o f the fwtus, parallel to the spinal column and on its left side, hut as it approaches the pelvis it curves tonards the right with the result that it seems to be continued into the right iliac while the left iliac appears to be a branch, is smaller, and receives a smaller supply of blood. Th i s inequality will be carried into their respective hypogastric branches. " T h e f e t u s floating freely in a fluid readily gives way to the recoil acting on its pelvis, and the right artery. having the greater power of recoil, will determine the direction of the rotatory motion which ensues. Thus, supposing the placenta t o be attached to the fundus of the uterus and the f e t u s floating n i th its face towards the placenta, then its rotatory motion will be bv its cephalic and pelvic ends passing in succession with regard ;o the uterus from right to left anteriorly. and from left to right posteriorly. Th i s rotation con-


Abnormalities of the Umbilical Cord 33 tinues until the natural rigidity of the vessels offers a sufficient resistance and they cease to yield further.”

Allen attributes the twisting to the grou-th of the arteries being more rapid than that of the veins, so that the former are obliged to take a tortuous course in order to accommodate their increased length.

Mute], Vermelin and Donibrav have recently explained torsion on mechanical principles and point out that a cylinder fixed between two plane surfaces, on or with one of n-hicli i t is free to turn, can only increase in length by assuming the form of a spiral. The cord they regard as a vascular cylinder contained between two planes situated a t a constant distance from each other. These planes are the placenta and the f e tus , and the constant distance is maintained by the tone of the uterine mall and suspension of the f e t u s in tlie -liquor amnii.

Causes of Pathological Torsion. Various causes have been invoked from time to time to explain this condition. It is most common in multiparrt: which is supposed to indicate that the laxity of the abdomen and the greater size of the uterine cavity allow free f e t a l movements and thus predispose to excessive torsion. Boys are more commonlv affected than girls, and it is supposed that the former are stronger and more active, and that the active movements are a n important cause. In Spiegelherg’s figures, of 99 cases reported by various authors there were 60 males and 39 females. According to Chantreuil. the chief predisposing causes are excessive f e t a l movements and an abnormally long cord. T h e last must be considered in relation to the fmtal age as the normal length of the cord at different periods of development is approximately equal to that of the f e t u s ; in most of the recorded cases the length of the cord considcrahly exreeded this standard. Spiegelherg states that very active movements of the fwtus are the cause, or the exposure of the bodv of the mother to violent and prolonged shocks. X similar euplanation has been invoked by Noegerath, who has seen three cases of excessive torsion following a violent fall. According to Ereit, excessive torsion can only occur n-lien the jelly of Wharton is scanty. Simpson, whose theory of the cause of physiological torsion was quoted above, thought that evcessive torsion was due to abnormal action of the heart in inflammatory affections of the f e t u s . A more liltelv explanation would appear to be that it is due to the causes of physiological torsion acting to excess on account of less than normal resistance by a vci-y thin cord to the forre that produces the twisting, the thinness of the cord being due to the absence, more or less complete, of the jelly of Wharton and affecting the whole or only part of the cord.

1)



Changes i n the Cord in cases of Excessive Torsion. Unlike physiological ti\ ists, those in tlie pathological variety rmiain permanent after separation of the ftr tus and the placenta. They can be forcibly untwisted, but on leaving g o one ol' the ends they at once regain their former appearance. In a specimen of pathological torsion in my posxsbion, olitained by Dr. William Fordyce from a macerated fetus, after forcibly undoing the twists in a short length of the cord it is seen that along onr surface corresponding to the inner mutuallv compressed surface o f the spirals the cord is flattened and there is a fibrous band z mni. broad which limits the stretching of the cord and causes it to be permanently convoluted, very much as the mesentery of the intestine being shorter than the intestine itself prevents it from tieing straightened out. On the opposite free surface tlie cord is rounded. I t is impossiblc that such a condition could have arisen after death. I mention this because previous to examination of this specimen I had thought that pathological torsion might be of post-mortem origin. Spiegelberg evidently believes that some originate after death. for he says (loc. cit., p. 478) : " post-mortem torsions can only be due to the f e t u s being twisted in consequence of movements of the mother." TI'hile thev may possibljr sometimes be of post-mortem origin, the case that I have described proves that they are not always so.

A case dcs-ribed b v Heanel, is of interest from the same point o f view. T h e patient jvas a priinig-ravida, aged 40, \\hose pregnancy was normal [inti1 ithin two weeks of the expected date of delivery, when she felt a violent commotion of the f e tus , after \\ hicli all movements ceased. Six dn!-s afterwards a macerated frrtus \\.as born, which shonrd no evidence of syphilis. The cord was markedly t\\ istrd. tlie strongest twist being about the centre, and both f e t a l and maternal ends were txxdemaious. TIC considers this e d e m a to be evidence that the torsion had evisted before death.

In my mvn case it was not more than 2-4 mm. in diameter- and ~ v a s of firm consistence. .Zt intervals there werc, however, three or four loc.ali;.ed accuniula- tions of jelly-false knots-the lai gvst of n hicli measured over I cm. in diameter. -41 these thicltened areas the cord was not twisted. T h e naked eye appearances are such that it seems impossible for an effective circulation to he maintained througli such a cord. Out of 8s cases collected b?. Dohrn from the literature, the state of the vessels \\as mentioned in 15 . Of these the vessels n c r e pe rm~ab le in TJ to injection o r a vc'r i fine probr, i n one thcy jvere pc.rnienblc only after untLvisting thtl cord, and in one thcy were completely impermeable. Dohrn, i n a case of his own, in uhich thc f e t a l length was r g inches and that of the cord 18 inches, the latter being 28 times twisted from right to left with a marked

T h e cord is L I S L I : \ ~ ~ ~ rwessivcalv thin.


Abnormalities of the Umbilical Cord 35 constriction at the f e t a l end in which there \\as only one twist, gives careful measurements of the vessels. In the stenosed part the vein had a diameter of half a line, a little above this part a diameter of 44 Iincs, and in the rsemaining parts of the cord, 4 lines. The lumen of the left artery was 2 lines, and in the stenosed part, half a line. The right artery had everywhere, including the stenosed portion, a lumen measuring 2 lines.

In in' own case microscopic examination shon ed that a t one end the vein was patent, but the two arteries closed. In the othei- end one artery \\as quite closed and the other almost so. There seemed to be no thickening in the nal ls of the vessels. T h e normal walls seemed to have adhered from pressure.

Occasionally the torsion may bv so extreme that the cord is twisted off close to the navel, as in the case described bv Hirsch occurring in a twin pregnancy. The first fcrtus was a dead born male at about the beginning of the sixth month of development the second entirelv healthy and a t term. T h e cause of death of the first tn in was a complete twisting off o f the cord so that the f e t u s lay free in the amniotic cavity.

Time at which Torsion occurs. Neugebauer is of opinion that pathological torsion usually develops during the fourth month. I n 64 cases Dohrn found t1;at in 1 3 the f e t u s at thc time of death had reached the end of the third month; in 15, four months; in five, five months; in eight, six months; in 22, seven months; and in one, eight months. It therefole most frequently occurs a t a time \\lien the f e t u s is small, and is able to move freely in the liquor amnii.

~ ,OC. \ I , lZED CONSTRICTION OF THE CORD. This in itself may htl a cause of fwtal death, as in one of my

cases, but i t is frequently asociated n i th excessive torsion. Not infrequentlv, however, localized constriction with associated \.ascular stenosis or obliteration is the only change present. In this condition certain areas of the cord are extremely slcndcr, and of a firm and fibrous consistence. The chang-e is most frequentlv found at the fcrtal end close to the umbilicus, where it involves ;he first inch or so of the cord. This nas its situation in seven caws described b v 1,andsbergcr. In a case described bv Froedrich there were numerous circumscribed areas of constriction throiighout the cord. Again the constriction mav be found a t the placental end alone. Sometimes the thin part of the cord may be (Iscessively twisted, as in the case of AndCrodias and Rrandeis. The patient was a primigravida aged 28, whose pregnancv was normal t i l l just hefore the seventh month when she notired that fcrta1 mowments


36 Journal of Obstetrics and Gynzcology

ceased. Six days afterwards a macerated child was born. There \{ere no signs of syphilis in foetus or placenta, nor could any cause of death be found, until on examining the cord, which was 40 cm. long. i t was seen t o be divided into t u o distinct poitions. T h e one toxvards the placenta was the longer and \ \as bulky in its entire length. T h e other or f e t a l portion 5-6 cm. long, was thin and became more so a s it neared the umbilicus. T h e thick part of the cord \%as scarcely twisted a t all, while the constricted portion Tvas markedly twisted, especially near the umbilicus. Microscopic examination of the t\\isted thin part showed narrowing of the umbilical arteries and thrombus formation within them a s though they had been ligatured. T h e umbilical vein was normal. Accord- ing to Dohrn, Braun, Chiari and Spaeth observed 19 cases of this kind Ivhich is probably, therefore, the most common variety. In Dohrn’s case there was but one twist in the constricted portion, which was close to the navel and about I cni. long. T h e rest of the cord was of medium thickness and was 28 times twisted from right t o left. The vessels of the cord nere sh0n.n by injection to be coni- pletelv permeable though their lumen was much narrowed. In my own series there is one case in which death ~ v a s apparently due to a localized constriction of the cord with arterial obliteration. The history was as follows :-

Three para, aet. 27. First child still-born, easy labour, a t term. Second full time, alive and well, aged two years. XIother seemed healthy ; no evidence of syphilis. lyassermann reaction negative. L.M.P. January 28th. No foetal movenients felt since July Arst, previous to which time pregnancy appeared normal, no movements being felt until August 25th. She was sent by her doctor to hospital, where fwtal death mas diagnosed and labour induced on August zgth, a dead fcetus heing born next day. T h e foetus, a much macerated female, neighed 750 grms., length .34.5 cm. Placenta 250 grms. ; decidual surface somewhat fibrous in appearance, and a t some parts from this surface areas of gelatinous looking tissue penetrated into the placental substance and sometimes almost reached to the fcrtal surface. Here and there was a little sub-amniotic blood clot. On section the placenta looked spongy, but thc vessels seemed abnorniallv thickened and stood out prominently, \vhilra microscopically the placenta u as ver! non-vascular but the villi were not enlarged. Mere and therc were one or tn7o still patent vessels, but the walls of these uere very thick so that the lumina \\.ere almost obliterated. T h e appearance was not that of a syphilitic placenta. Cord 18 inches long, brown and macerated, but otherwise seemed normal escept for a small part at its root(t1ie f e t a l end) about $-inch i n length, i n w1~ic.h the cord was extremely firm and slender, being onlv 2-3 mm. in diameter. There



was one twist in the cord at this point. It looked as if the jelly 1% ere absent. The liypogastric arteries inside the abdomen appeared to naked eye examination to be normal, and the same applied to sections of the cord taken elsen here. Rlicroscopically, the arteries in the constricted area were completely obliterated. The vein was still patent but tlie lumen small. T h e jelly of Wharton was very fibrous and had not the normal myxoniatous appearance. The lumina of the arteries seemed to be occupied by fibrous tissue, which was intimately blended with the vessel walls so that but little trace of the latter remained.

It is difficult in this case to say what was the primary condition. There are two possibilities : ( I ) that there u’as a localized fibrosis ol’ tlie Wliartonian jelly which caused pressure obliteration of the arterial lumina. There is, however, no evidence in the microscopic sections that there is a mere udhesion of the arterial walls to each other. There is rather a nexv formation of fibrous tissue inside the arteries, and tliis maltes more likely the second explanation, viz. ( 2 )

that the primary condition is an arteritis obliterans with thickening of the tunica intima and tunica adventitia, the latter secondarily in- volving and leading to fibrosis of the Whartonian jelly surrounding it. In tliis connexion a case described by Cavasse is of interest. T h e mother was healthv and in her second pregnancy ; the pregnancy nas normal until the eighth montli \\lien movements ceased to be felt. The f e t a l heart was no longer heard and the fcetus was born by the breech 2 0 days later. The placenta was normal and the cord showed the usual appearances to about a distance of 2 cm. from the umbilicus, a t iiliich point it became narrowed to the thickness of a small penliolde,-, and was hard and fibrous and not twisted. On section of the cord, a centimetre from the point where nnrron ing began. a clot nas found in the vein, a t first red and soft, then becoming firm, hard and white, and adherent to the nall a t the narrowed part but still easily separated. The lumen of the vein at the narrowed part n7as not more than one-third of that a t the normal part. The walls Tvc’re more thickened and the jelly of Wliarton completely absent. The \ (in, emptied of its clot, was permeable though of small volume. The liver was small, but the other organs were not examined. Cavasse thought the condition a phlebitis and that it had existed for some time before death. There was no specific history nor other circumstance to explain the occurrence. The cord was not twisted nor subjected to pressure, neither had there been any fall or blow on the abdomen. The phlebitis had evidently lasted for some time; the fetus was of small size, considering its age, so its nutri- tion ivas probably interfered n.ith ; the f e t a l movements were very pronounced during the two or three days preceding their entire cessa t ion.


38 Journal of Obstetrics and Gynzecology

In niy o n n case it is dificult to dissociate the cord lesion from tlie obliteration of the vessels in the placenta. T h e condition is probably an arteritis oblitcxrans of ohscure 01 igin affecting the intinia and adventitia of the cord v( rls as well as those of the placenta. In the case of the foiriier the fibrosis had in all proba- bility spread to and involved the IVlmrtonian jell\. and thus caused the area of localized constriction. A similar explanation is probably correct in the case of C'avasse, although here thi ombosis set in before the venous lumen was obliterated.

SYPHILIS o~ THE CORL). The most frequent histological tinding in cord syphilis is round

cell infiltration of the \\ails of the vessels. It affects the \\all o f the w i n more frequently and more intensely than that of the artery. T h e entire circumference of tlie wall o f the vein may be infiltrated and the jelly of IVliarton immediately surrounding, or it may affect chiefly or entirely the outer third. In one of my specimens only one side of the vessel \ \as affected and the other had entirely escaped. The artery may stlo\\ a similar change, but it is less frequently found than i n the vein and is rarelv so intense as i n the latter. T h e nuclei of the round cells are usually undergoing karyoi rl.exis. This inflaiiimatol->- reaction is sometimes the on ly change evident, and the vessel nall , whethei artery or vein, may show no increase in thickness. Sometimes, hov ever, there is found a marked proliferation o f the tiinica media which may almost or entirely obliterate the lumcn. This. in m y experience, is most frequently found in the more virulent cases of syphilis, especiallv in the cords of fresh infants born prematurely and whose organs contain spii-ochaetes and shon. \\ ( a 1 1 marked SJ pliilitic changes. In all my cases tliis thickening is entirely of the tunica media, the inner zone of muscle being cydematous and vacuolated, and the nuclei of the muscle fibres and of the connective tissue cells undergoing Iraryorrliexis. I t is unusual, in mv experience, to find intimal thickening, although the latter is the principal change described by some observers.

hether the hypertrophy of the media is due to syphilis o r is merely a \\ ork hypertrophy consequent upon the endarteritis obliterans in the placental vessels. Probably the latter is the correct explanation. T h e phlebitis inny lead to thrombosis n i t h complete closure of the lumen and consequent death of the fie t u s.

,Sfiirochci,tcs in l l z c c o r d . Grafenhcrg, i n I C ~ C ) , reported that in ,3g spil-ochzte positive faatuses he had found the spirochxtc in t1-c. umbilical cord in every case. Bab found then in only 9.4 per cent., and Rlohn in 78 per cent. of spirochaete positive fmtuses. Emmons

It is doubtful


Abnormalities of the Umbilical Cord 39 found them in one of three spirochzte containing fetuses , but in none of 2 7 other cases suggestive of syphilis. I l e concludes that they are only larelj found in the cords of syphilitic Infants, that a large proportion of infants shou n to be syphilitic by examination of the placenta, as well as by characteristic post-mortem findings, I\ ith spirochztes demonstrable in the liver, failed to reveal spiro- chates in the cord af ter extensive search, and that a negative diagnosis cannot be made by examination of the cord alone. rlccording to Grafenberg, they are much more likely to be found close to the f w a l end, rarely tonards the placental end. They are found most often in the walls of the vessels, and especially in that ok the vein, chiefly in the media and diminishing in numbers towards the adventitia and the intima. Seldom does one find an isolated spiroclwte in the jelly of Wharton. 1':xaniination of the f e t a l end of the cord may therefore yield valuable confirmatory evidence of the presence of syphilis in the f e t u s ; indeed, Grafenberg goes so far as to say that spirochxtes are always present in the cords of congenital syphilitics, wlwther fresh or macerated, and that i f spiroclixtes are demonstrnblc in tlie cord there are almost always other signs of syphilis in the child, such as peni- pliigus, htt.niorrhagic diatliesis etc. I t is noteworthy, however, that h r failed to demonstrate spirochietes in the cords of eight apparently healthy fwtuses born of syphilitic mothers, three of whom suffered at birth from secondary s) pliilis. This would s9em to be conclusive evidence of the Invalidity of his statement that spiroclmtes are allvays present in the cords of congenital syphilitics. \ire knon that spiroc1i:etes are not alwa> s demonstrable in the organs of sypliilitic infants, and it tlirrefore seems unieasonable to exclude sppliilis because spirocketes are not found in the cord.

I have found spiroch~etes in the umbilical cord of only one macerated fwtus. The organs were spirochiete positive, but a very careful examination of the placenta proved negative. T h e organisms were present in fairly large numbers in the tunica intima of the vein but not in tlie media or adventitia, and so close were they t o the lumen that in several instances one end of the oyganisni projwted inlo it. l n several cases, examination of the cord of spirochzte containing f e tuses proved negative. I must confess, Iiowever, that pieces for examination were taken a t random from any part o f the cord and not necessarily from the f c t a l end, and to this probably can be attributed my frequent failure.

OTHER R.Zw 1 , ~ s r o N s 01; T H E C'oizu. ABSENCE OF THE CORD.

Complete absence of the cord is not necessarily incompatible ni th deve'opment of the fetus to t r r n i . L l n ipstance of this


40

interesting condition is reported by Stute. The mother as at her fifth confinement, all the other children being normal. The concli- tion \ \as felt on examination during labour and the f e t u s nas extr‘tcted, Tvithout the occurrence of hzemorrhage, by traction on the Itnee. O n tlie back there was a cystic suelling, and to tlie abdomen, tlie placenta, normal in size, was attached over an area of 4 cm., the centre ol attachment being at the umbilicus. There was no vestige 0,. a cord. T h e child was born dead and macerated a t the eighth month. There \\ere liydi-ocephalus and exoniphulos present, and the vessels of the cord were probably really present and spread out on the surface of the sac.


The child was very small, but a t full time and alive.

Another case was recorded by Madame Danthez.

1,OCALIZEl) \rARICOSITIES ON THE ( h K D . varicosity of the unihilical vein with rupture six inches from

the placental insertion and consequenl death of the fcetus has been described by Pluskal. In de Zoninitz’s case the cord nas bent into an acute angle at a distance of 1.j cni. from its placental insertion. .It the extremity of this angle there \\as a varicosity as large as a lien’s e g g u i th a thin and ruptured wall. Dougall (quoted by Chantreuil) Itas recorded a case of an arterio-venous aneurism the size of a hen’s egg, at about two inches from the placental insertion. Its walls Lvere formed by the tunic of the cord, and the pouch contained a dark coloured clot surrounded by layers of fibrin. T h e f e t u s had been dead for a long time, judging from the advanced stage of maceration.

ULCEllATION OF THE CORD. A specimen that was probably unique was that recorded by

Jenkins, of hmnorrhage into tlie amniotic cavity resulting from ulceration of the umbilical vein. H e attended the patient in premature labour from albuminurin a t the end of the eighth month. O n examination, he found the membranes intact, and when they ruptured the liquor discharged was seen to be almost pure blood. The child mas dead and very pallid--apparently exsanguinated. I Ie estimated that there was a t least a quart of blood in the amniotic cavity. A small perforation was found in the umbilical cord about half an inch from its abdominal insertion. The cord was much narrowed at this point but not twisted. An examination of the affectcd portion revealed the fact that the jelly of Wharton was absent in one spot of a diameter of one-sixth inch and in the depth of th: defective mass there \\.as an opening into the umbilical vein. In the part of the vein surrounding the opening the unstriped muscle of its wall had undergone fatty degeneration, which n a s the cause of rupture.



H&:MATOMA OF THE CORD.

Several ca5es of this condition have been reported. In some of tlie cases, but by no means always, it has led to f e t a l death. T h e Iizmatoma arises froin rupture of the umbilical vein by trauma (as in Couvelaire’s case), torsion, varicosity, or on account of velamen- tous insertion. The blood contained within tlie amniotic sheath infiltrates the jelly of Wharton over an aiea of variable extent, compressing the vein and possibly also the arteriesof the cord. T h e size of the hzmatoma varies. In Stocker’s case (vide znfra) it was the siw of a pigeon’s egg, in Pluskal’s case the size of a hen’s egg, in Wolsterdorff’s case tlie cord nas as thick as the thigh of the f e t u s , and in Ritter’s case the sueelling was 17 cni. long and measured 64 nini. in its greatest girth, F e t a l death is as a rule not due to the amount of hzmorrhage but to pressure by the clot upon the umbilical vessels, especially the umbilical viein, or to the formation of a coagulum in the lumen of the latter a s in Stocker’s case, of \\ liicli the details are a s follows :-

hlarried in spring, 1879, and soon thereafter became pregnant. Last menstrual period end of May. T h e pregnancl was in no way abnormal and morning sickness, a t first some\\ hat severe, was gradually controlled. To\\ ards the 20th

ecli f e t a l movements were first observed and continued normal until three days before delivery when they became extremely vigorous and then ceased altogether. On 29th February labour pains started, delivery being acconlplished by easy forceps early next morning. The f e tus , a male, was premature, \veil developed, but dead and slightly macerated, the skull bones being movable, the sutures wide and loose and the epidermis on the scrotum detached in shreds.

O n the unibilical cord an interesting condition was found. Near the middle of the otherwise normal cord there was a bluish swelling the size of a pigeon’s e g g . I t lay o n the side of the cord and occupied about half its circumference. Examination revealed the following facts :--

(u) The umbilical w i n ~ a s considerably dilated at thc site of the swelling so that its lumen could hold a hazel nut.

(6) This widened part was filled with a solid but unorganized clot.

(c) After removal of this coagulum a lacerated opening was visible in the w7all of the vein, large enough to admit the head of a pin. The clot in the dilated vein protruded through this opening and was continuous with a firm coagulum situated under the amniotic sheath of the cord.

ere permeable but somewhat displaced.

Frau F., z t . 22.

(d ) The cord arteries



(c) The swelling of the cord was due partly to the dilated and obstructed vein and p n r t l ~ to the clot undler the amniotic slleatll.

I n this case the fcetal death nas evidently due to obstruction of the vein by tlie clot, but this is not a l ivays fatal, for the obstruction may be incomplete as in Kronier’s case i n \\ hicli tlie circulation was maintained through a cliink bet\veen the h rombus and the vein wall, or in Wolsterdorfl’s case in which a smooth circular tunnel allowed the blood to pass through the centre of the clot. In Chvelaire’s case the child M ~ S born alive and well but the Immatoma \\:IS onl! formed during labour and after birth of the head. The cord was wound around (lie child’s neck and in slipping it over the head the vein must h a w been injured. The haematonia \\as a very large one, occupying an extent of 10 cm. and stopping I cm. from the umbilicus. T h e wound in the vein was only 1.5 mm. in diameter and part of the clot infiltrated the wall of the vlein, sepnrating the outer from the middle coat. If the foetus in these cases dies only during labour and is therefore expelled in a fresh condition it may show all the appearancrs usually associatled with asphyxia, such as lividity of the mucous membranes, injection of the conjunctiv:e and congestion of the internal organs. This is explained by the back pressure of the blood from the obstruction in the umbilical vein through the placental capillaries and the umbilical arteries, this being no doubt facilitated by the compnra- tively slight difference between the blood pressure in the umbilical arteries and that in the umbilical vein. A! similar condition in the body of the foetus would arise i f the extravasation of blood in the cord obstructed the circulation through all three vessels. The following case recorded by Ritter is of intlerest from this point of view.

T h e child mas premature, dead not more than an hour before birth, and was the first of hcealthy parents. The birth had been normal, the cord not being around the neck. The heart sounds had been heard bv the mcxdical attendant till within an hour of birth when they were strong and regular. After that they were not sought for and so the exact time at which fcetal death occurred was unltnown. O n birth of the head the blue discolouration of the lips ~ v a s evident as well as the swollen and injected conjunctiva The cord was 69cm. long, and in the placental portion ther’e was no pt l iolog ical change. Beginning I cm. from the abdominal \\all and extending along the cord for 17cm. was a large haeniatonia, dark blue in colour, of which the greatest diameter was 38 mni. and the greatest girth 64 min. The portion o f the cord next the placenta showed no pathological change to the naked eye, and microscopically



tlie umbilical vessels appeared quite normal. O n examination of the cord a t tlie site of the hxniatonia tlie follov ing appearances were obserrcd. There \i as a n extensive lizerziorrliage underneath the amniotic slieatli distending it and infiltrating tlie jelly of Wharton. The arteries were contracted and tlie vein collapsed, but its lumen increased. At the point of greatest widening of the lumen the wall oi tlie vessel was torn througli. I2ilicroscopically the walk of the vein \\:is inliltrated with blood and the intima absent. There was no deficiency in the elastic tissue nor any evidence of inflammation.

Post-mortem examination of the f e t u s showed that the vessels of the cord inside the abdomen were normal, the foramen ovale and ductus Botalii patent, and that the cause of death was asphyxia. Iiittcr attributes the rupture to a pre-existing varix, and adopts the vieu 01 Dolirn that such varices may arise from physiological torsion of tlise cord \\ liicli kinks tlie thin-walled vein and thus leads to dilatation behind the liink.

-1 RARE AUNORhlALlTY OP THIS \: ELS OF THE CORD. Microscopic examination of tlie cord of a premature infant

\\ hich came under nij ob.wrvation revealed the following- probably unique condition of matters. There was but one artery, and instead of a vein there were nuiiiercms capillaries and a few vessels with a little fibrous strorna in their walls scattered throughout the jelly. The jelly of Whai-ton Lvas much denser than usual and, indeed, \\as a fairly dense stroma in which the vessels lay embedded. Here and there the capillaries had ruptured and blocd in small quantities ivas effused into the stroma. The infant was born prematurely a t the sixth month alive and well formed, but died in a few hours. There was nothing in the history or post-mortem findings suggestive of syphilis.

CYSTS OF THI.: ITAIHILICAL CORD. According to Haas cysts of the cord may arise from :- ( I ) T h e allantois. Haas, writing in 1906, could find only t\vo

cases recorded in the literature, uiz., those of Ahlfeld (Arch. f. Gyn. , Bd. 10) and Ruge (Zeitschrijt. f. Geb. u. Gyn., Bd. I),

(2) Tho umbilical vesicle. ( 3 ) T h e jellv of Whaston, either (u) from liquefaction of a

Ii:einatoiiia, but no case of cyst formation from this cause has yct been demonstrated ; (6) from liquefaction of the jelly of Wharton itself. Of this inanv caw5 have bevn described (Scanzoni, Idass, Ruyscli and Heyfelder). Those arising from the allantois and from the umbilical vesiclr have an epithelial l i n i n g and are thfercforr? true cysts, but those arising from the jellji of Wharton cannot be 51) dvscribed.

(4) Inclusions of amniotic epithelium.



Cysts of the cord are usually w r y small, the largest described being about the size of a hen’s egg. The smaller ones are of no clinical iniportance, but it is possible that a large cyst might cause death ok the foetus through compression of the umbilical vein. T h e only recorded case of f a t a l death was that recorded by Scanzoni (quoted by Hass). T h e c j s t was thc size of a hen’s egg and apparently arose from liquefaction of the jelly of Wharton.

SOLID Triaroui<s OF THE CORD. Only eight cases of this rare condition appear to have bleen so

far recorded in the literature. ( I ) T h e first casc W ~ S described by Maunoir in 1820. T h e

child had 11 hernia into thr umbilical cord \\ hicli was crowned by a strawbferry-sized fungating tuniour. He removed it with complete success a t the age of seven months.

( 2 ) In Lawton’s case, a tumour the size of a pear, n a s situated in the base of a hernia of the umbilical cord and had a telangiectatic structure, but neither this nor Maunoir’s case appears t o have been histologically investigated.

I t was four inchces long, a s thick as a forefinger and shaped like a cow’s horn. I t entered the navel with the cord and on its base were several smaller protuberances. At birth it was bright red, fairly firm, without pulsation, not diminishable in size by compression, was very smooth and vascular and had a covering of pavement epith le 1’ ium. I t was removed successfully at the eighth day o f the child’s life. Virchow described it as a telangiectatic mysosarcoma.

(4) T h e fourth case was examined by Kaufman and reported by him in Virchow’s Arcliiv. Bd. 1 2 1 . S. 513.

It was removed by Lissner in I’osen in 1890. The tumour measured 16 x G cm. Underneath it was covered by the outer sheath of the cord, above a mantle-like membrane, obviously the amnion, which passed over the cord, while the cord ran along-side of and was incorporated in the tumour. Removal was successful.

( 5 ) v. Winckel’s case. T h e child was born alive and a t term, and was fairly well nourished. At birth was noticed an irregular bright red tuinour of moderately firm consistence growing from the side of the cord close to its root. T h e tumour was 4 cm. long, 2.8 cm. thick a t its base, and near its apex 1.6 cm. It was removed by the cauterv on the day after birth and the infant did well at the time but died of catarrhal pneumonia 2 0 days later, the latter being quite unconnected with the tumour or the operation. T h e tumour was a telangiectatic rnyxosarcoma with large numbers of neu

( 3 ) Gerdes’ case, in a child a few hours old.

This tumour also \\as a telangiectatic myxosarconia.



vessels and also of lymphatics-very dilated and lined by a rapidly proliferating epithelium.

(6) Herweg’s ca.se. This differs from all the others in that it was situated close to the placenta. I t ~vas a solid tumour with four smaller projections from the main mass. One of these \\as large and broad based, lvhile three were globular and bladder like. T h e largest bladder \\as the sizc of a cherrj , the second of a cherry stone, the third of a hemp seed. T h e main tuniour was kidney shaped and on section its consistence and appearance resembled a fibromyoma. Length 5 cm., height 3.3 cm., breadth 3.2 cm. Section of the tumour showed calcified areas and obliquely cut vessels. Microscopically, the outer pait o f the tumour nas formed of a non-vascular jelly-like ground substance pervaded by numerous firm wavv bundles of connective tissue fibrils and here and there spindle, ;od and star shaped cells Lvith oval nuclei. This was probahlv the norni:il jelly of IVliarton stretched over the surface of the tuniour. T h e true tuniour mass lay inside this covering, and was formed of ground substance like that of the latter, but was pervaded by very numerous vessels, all of which mere lined by vndothelium. The vessels anastomosed fieely with one another and had narrow luniina. Surrounding the endothelium and forming the vessel walls were muscle cells arranged in one, two. three or more layers. Some of the vessels, however, had only an endothelial wall. The tumour was diescribed by Herweg as a myxangioma. T h e origin of the vessels contained in the tumour was, according to Herweg, as follows: A short distance o n the f e t a l side of the tumour one of the cord arteries gave off a small branch which ran separately to the placenta; this in turn gave off a small branch which divided and re-divided in the tumour. T h e child was born alive and well a t full time.

(7) Cuse of Budin . Fourth pwgnancy. First three labours normal ; present lahour also normal ; the child, a \tell nourished female, was also alive and nell. The tumour, which \\as the size of a large adult fist (8 x 6 cni.), was situated 2 0 cni. from the umbilicus, surface smooth but bossed. Clolour dirty greenish vello\\. Tts interior showed three distinct cavities, the first of which contained chocolate-like i i~ater id , the second material like Ivhite of egg, and thv third a creamy substance resembling vernix cnseosa. The umbilical cord \ \as incorporated in the border of the tumoiii and cnntained the usual number of vesscls. none of which communikatcd with the c!.st cavities. On the inner uall of one of the pouches there ivere several small projections of variable shape and size. The nails o f the cavities nere lined by pavement epithelium like that of the skin, and beneath this there was a Connective tissue layer with numerous sebaceous and svea t glands


46

and hair follicles. In the second cavity, alongside of areas of dermoid type, there \yere other parts showing villi like those of the intestine, and covered by columnar epithelium. More deeply there were large numbers of tubular and niucous glands and smooth muscle fibres cut in various directions. The third cavity n a s lined by columnar ciliated epithelium. In the solid parts of the tumour, beside adipose tissue and smooth muscle fibres, there \Yere large vessels, nerves, and nodules of cartilage and bone. T h e tumour n as thus a teratoma.

(8) Windle ( ] I . i l n u t . and I’hysiol., 1891, Vol. xxv, p.441). reports a dermoid i n the cord o f an anencephalic fe tus . The case mas originally reported by I<aufinann (Virclion’s Archiv Rd. cxxii, lift. 2, S. 381). T h e tumour \\as of firm consistence and almost spherical in shape iwasuring 16 cni. in diameter. I t \\as attached to the cord close to the abdomen, t o nhich its base nas connected. Microscopic examination of the rimo our shoned that it consisted in part of numerous branching and partiallv cavernous wssels, and in part of myxomatous and emhryonic tissue, the author describing it as a myxosarcoma telangiectodes.


SUMMARY. I . True knots may exist on the umbilical cord during intra-

uterine life without endangering the life of the f e tus . They, hoxvever, sometimes obstruct the cord circulation sufficientlv to cause fwtal death.

2 . \\‘hen knots have esisted before the onset of labour they s h o ~ ~ certain anatomical pecuIiaritics I\ hich serve to distinguish them f roni Imots f n r med during Inhou r.

3. Encircleinent o/ tlac chi ld’s n e r k b y loops o! cord may cause antenatal dr.ath. I n such cases the soft parts may he sn compressed against the vertr1)r:iI column that tllc f t r t a l head may be almost a ni p u t at ed,

4. Bxccssiile torsion o/ the cord is a rare cause of f e t a l death. T h e causes of physiological and pathological torsion are discussed, and it is conrluded that an important cause prpdisposing to exes- sive torsion is insufliciencv of the 1Vhai-toni:in jelly. The cord vessels in these cases a<e u s u n l l ~ impervious.

5. Localised coizstricfion o / / h c > cord is another not infrequent cause o f fwtal death ; i t is most cninmon in the fmtal end of the cord close to the navel, b u t ma! affect sevrral portions o f tl!c cord or rarel? t h e placclntal end alonc. I t is prob:ti)le that tlic m u s e is an obliterating endarteritis, affecting t l i c intima and ad! cntitia of the vessels, thr fibrosis spreading to thp jc>lly o f TVIiarton.

6. Syphilis of t h r c o r d : ‘P~c~ histolog! of the cord in this condition is discussed ; the chicf change is round cell infiltration of the



wall of the vein, and proliferation, with vacuolation of the muscle cells and edema , of the tunica media. Phlebitis \vitli thrombosis 111a~. also occur. Sp i rochz~es are most frequently to bte found at thc f e t a l end, and chiefly i n the vein wall.

7. Hamatoma of the cord may sometimes lead to f e t a l death. The hxmiatoma is due to rupture of the vein from varicositj-. torsion of the cord, or injury during labour.

8. Details are given of eight cases of solid turnour of the cord. In three cases the structure was that of a telang-iectatic myxosarcoma, in two it was a teratoma, in one a mvsangioma, while in two others Iiistolog-ical invcstigntion \\as not carried out.

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1925 - browne - cord abnormalities and iufd

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